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MED SURG EXAM 2 QUESTIONS AND ANSWERS
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MED SURG EXAM 2 QUESTIONS AND ANSWERS
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MED SURG EXAM2 QUESTIONS
AND ANSWERS
You are the nurse caring for a female pt who developed a pressure ulcer as a result of
decreased mobility. The nurse on the shift before you has provided pt teaching about
pressure ulcers and healing promotion. You assess that the pt has understood the
teaching by observing what?
a. patient performs ROM exercises
b. pt avoids placing her body wt on healing site
c. pt elevates her body parts that are susceptible to edema
d. pt demonstrates the technique for massaging the wound site
b
An elderly female pt who is bedridden is admitted to the unit bc of a pressure ulcer that
can no longer be treated in a community setting. During your assessment of the pt, you
find that the ulcer extends into the muscle and bone. At what stage would document this
ulcer?
a. I
b. II
c. III
d. IV
d
The nurse is providing care for a 90-yold pt whose severe cognitive and mobility deficits
result in the nursing diagnosis of risk for impaired skin integrity due to lack of mobility.
When planning relevant assessments, the nurse should prioritize inspection of what
area?
a. pt elbows
,b. soles of pts feet
c. pt heels
d. pt knees
c
While assessing a newly admitted pt you note the following: impaired coordination,
decreased muscle strength, limited ROM, and reluctance to move. What nursing
diagnosis do these s/s most clearly suggest?
a. ineffective health maintenance
b. impaired physical mobility
c. disturbed sensory perception: kinesthetic
d. ineffective role performance
b
You are the nursing caring for a pt who has paraplegia following a hunting accident. You
know to assess regularly for the development of pressure ulcers on this pt. What
rationale would you cite for this nursing action?
a. you know that this pt will have a decreased LOC
b. you know that this pt may not be motivated to prevent pressure ulcers
c. you know that the risk for pressure ulcers is directly relation to duration of immobility
d. you know that the risk for pressure ulcers is related to what caused the immobility
c
You have been referred to the care of an extended care resident who has been
diagnosed w/a stage III pressure ulcer. You are teaching staff at the facility about the
role of nutrition in wound healing. What would be the best meal choice for this pt?
a. whole wheat macaroni w/cheese
b. skin milk, oatmeal, and whole wheat toast
c. steak, baked potato, spinach and strawberry salad
d. eggs, hash browns, coffee, and an apple
c
You are the nurse caring for an elderly adult who is bedridden. What intervention would
you include in the care plan that would most effectively prevent pressure ulcers?
a. turn and reposition the pt a minimum of every 8 hrs
b. vigorously massage lotion into bony prominences
c. post a turning schedule at the pts bedside and ensure staff audience
d. slide, rather than lift, the pt when turning
c
The triage nurse in the ED is assessing a pt who has presented w/ c/o pain and swelling
in her right lower leg. The pts pain became much worse last night and appeared along
w/fever, chills, and sweating. The pt states, I hit my leg on the car door 4 or 5 days ago
,and it has been sore ever since. The pt has a history of chronic venous insufficiency.
What intervention should the nurse anticipate for this pt?
a. platelet transfusion to treat thrombocytopenia
b. warfarin to treat arterial insufficiency
c. antibiotics to treat cellulitis
d. heparin IV to treat VTE
c
A pt w/a family hx of allergies has suffered an allergic response based on a genetic
predisposition. This atopic response is usually mediated by what immunoglobulin?
a. IgA
b. IgM
c. IgG
d. IgE
d
A pt has developed severe contact dermatitis w/burning, itching, cracking, and peeling
of the skin on her hands. What should the nurse teach the pt to do?
a. wear powdered latex gloves when in public
b. wash her hands w/antibacterial soap every few hours
c. maintain room temperature at 75F to 80F whenever possible
d. keep her hands well-moisturized at all times
d
An adolescent pts history of skin hyperreactivity and inflammation has been attributed to
atopic dermatitis. The nurse should recognize that this pt consequently faces an
increased risk of what health problem?
a. bronchitis
b. systemic lupus erythematosus (SLE)
c. rheumatoid arthritis
d. asthma
d
The nurse is planning the care of a pt who has a diagnosis of atopic dermatitis, which
commonly affects both of her hands and forearms. What risk nursing diagnosis should
the nurse include in the pts care plan?
a. risk for disturbed body image r/t to skin lesions
b. risk for disuse syndrome r/t to dermatitis
c. risk for ineffective role performance r/t to dermatitis
d. risk for self-care deficit r/t to skin lesions
a
, A pt has presented w/ s/s that are consistent w/contact dermatitis. What aspect of care
should use nurse prioritize when working w/this pt?
a. promoting adequate perfusion in affected regions
b. promoting safe use of topical antihistamines
c. identifying the offending agent, if possible
d. teaching the pt to safely use an EpiPen
c
The nurse is an ambulatory care center is admitting an older adult pt who has bright red
moles on the skin. Benign changes in elderly skin that appears bright red moles are
termed what?
a. cherry angiomas
b. solar lentigo
c. seborrheickeratoses
d. xanthelasma
a
While assessing a dark-skinned pt at the clinic, the nurse notes the presence of patchy,
milky white spots. The nurse knows that this finding is characteristic of what diagnosis?
a. cyanosis
b. addisons disease
c. polycythemia
d. vitiligo
d
While waiting to see the physician, a pt shows the nurse skin areas that are flat, non-
palpable, and have had a change of color. The nurse recognizes that the pt is
demonstrating what?
a. macules
b. papules
c. vesicles
d. pustules
a
An African American is admitted to the medical unit with liver disease. To correctly
assess this pt for jaundice, on what body area should the nurse look for yellow
discoloration?
a. elbows
b. lips
c. nail beds
d. sclerae
d
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